Should We Incentivize Physicians In CDI?

Dr. Terrance Govender

Jun 07 2017

Achieving physician engagement in CDI has been an uphill battle for a very long time and continues to be so for most organizations. There are approaches that have worked well for some and not so well for others. In order to understand why physician engagement has been such a challenge, I touched on a few main reasons on the ‘Top 5 reason your physicians are not engaged in your CDI program’ blog post because I think it is important to understand why the problem exists before we attempt to introduce potential solutions.

To adequately address the “What’s in it for me?” question posed by physicians when encouraging them to participate in the CDI effort, many organizations have turned to monetarily incentivizing them for their participation and contributions. I have seen this done in many ways and all but one of our clients have used monetary incentives in the form of group-level quality bonuses. This is what I can share with you based on our experience with this approach: This type of incentivization appears to work well when we use the correct metrics to base it upon. Unfortunately, the query response rate is not one of those metrics.

As I have mentioned before, there are too many influences outside of a physician’s control that would also affect their “bonus” payments. My opinion is that you should not be incentivized to do your job, and providing clinical documentation that is complete, accurate, clinically competent, and compliant is part of a physician’s job. That being said, I do appreciate why certain organizations have adopted the practice of incentivizing their physicians for their efforts related to CDI.

Interestingly enough, there is a science as to what motivates and drives individuals to perform and I think it’s worth sharing a summary of that if our goal (as it should be) is to affect long-term improvement in physician documentation practices. In his book ‘Drive: The Surprising Truth About What Motivates Us,’ Daniel H. Pink offers evidence that the carrots and sticks method is so “last century” and that this needs to be upgraded. He outlines three different types of motivation:

Motivation 1.0 was all about survival and obviously served our cavemen ancestors very well

Motivation 2.0 is essentially built around external rewards and punishment (carrots and sticks)

Motivation 3.0 is more relevant today and represents a more intrinsic type of motivation, which is the opposite of 2.0

The book discusses the results of an MIT study that gave a group of students a set of challenges or tasks that ranged from physical tasks to more complex cognitive tasks. They monetarily incentivized the performance of these students based on three main categories with corresponding dollar amounts: Low performance, average performance, and great performance – a concept very familiar in current business motivational schemes. Here’s what they found:

As long as the task involved only mechanical skills, bonuses worked as expected: The higher the pay, the better the performance. However, as soon as the task called for even rudimentary cognitive performance, a larger monetary reward led to poorer performance. This seems to defy the laws of behavioral physics and, as a result, the study was repeated with different students in other parts of the world, producing the same results over and over again.

How would those results be applicable with CDI? Well, I would consider answering a query a mechanical task, so if you incentivize the clinician to answer queries, you will get queries answered. However, I would consider the act of providing complete, accurate, and compliant documentation upfront a more clinical and cognitive task, in which case, monetary incentives might actually backfire on us.

With this in mind, I think it’s important to go back to what your goals are for the CDI program and ask yourself how they align with the overall goals of your organization. Is it to create a workhorse in the form of a query-answering physician? Or is it to create a culture where the physician strives to do it right the first time?

Like most things, there is some overlap here, as we do want physicians to engage and answer queries, but we also don’t want them receiving repeated queries on the same diagnosis month after month. As a fact: If you incentivize me to answer queries, I may tend to provide subpar documentation, wait for the query, and then cash my check. Don’t judge me, I’m only human.

Look, the CDI profession is not going anywhere, just in case some of you are concerned about job security. The ever-expanding scope and linkage to other hospital initiatives and clinical documentation is not going to be matched by a physician who has improved his or her basic documentation skills.

However, there is plenty of room for physicians to improve on the basics of what is needed for complete and accurate documentation of high-impact diagnoses. In order to get a physician to actually change their behavior on these basic requirements, your organization will have to adopt ‘Motivation 3.0’ strategies, not ‘Motivation 2.0.’

Daniel Pink outlines three facets of ‘Motivation 3.0’ that are crucial to positively affecting performance:

Autonomy: This speaks to our default setting of being autonomous and self-directing, and is very different from the “management” model.

In CDI, this can involve having your clinicians play an integral role in the approval of clinical definitions that are widely accepted in the industry, or even the software that may assist them in achieving accurate documentation.

Mastery: This involves getting better at something that matters. It demands effort, grit, and deliberate practice.

This is where accurate metrics on true documentation quality come into play. Remember, answering a query is a metric that is supported by 2.0, not 3.0, where the goal is to affect a long-term change in behavior.

Purpose: By nature, we all seek purpose. To contribute and to be part of a cause greater than just ourselves.

If the goal of your program is tightly aligned with the overall goals and mission statement of your organization, and those goals are successfully communicated to your physicians, evoking a sense of purpose with regards to improving documentation becomes far easier. This is a step, I believe, that is missing in many CDI programs across the country.

In summary, if you are incentivizing your docs for participating in your CDI program, please ensure that you are using the right metrics. Studies suggest that you are probably not going to affect a long-term change in physician behavior since that outcome requires some level of conceptual, cognitive, and creative thinking.

As you may know, I am a proponent of changing the documentation culture of an organization rather than checking off a box. The long-term results are very beneficial and, while not for everyone, that concept will resonate well with the visionaries in CDI and healthcare as a whole.